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Hey all, interesting rare case to share…
27 yo male PE teacher, active participant in recreational sports and regular exercise routine.
Chief complaint: intermittent, nonvariable, deep ache in L groin region that feels like “pulling” sensation on L testicle.
Pain: avg: 1/10, best: 0/10, worst: 1/10, current: 0/10
Initial onset in 2015 training for NYC marathon. Pt felt the pain during multiple training runs in a sporadic, inconsistent pattern. He reports also feeling it at random times during flag football, kickball games but in no consistent pattern.
PMH: unremarkable
Imaging: (-)
Previous Tx: Pt reported (-) exam by GP for hernia and testicular abnormalitiesAggs:
occasionally during running/sprinting, playing rec sports, swimming – all at random intervals and random times.
stiffness after long car rides at timesEases:
rest, heat, stretching sometimes helpsObjective Exam:
Functional Tests:
Unable to provoke symptoms with all of following tests:
SL stance
SL squat
DL squat
step up/down
Broad jump SL and DL
skier hops lateral
SL hop
fwd lunge stretch, lateral lunge stretch bilatLumbar ROM:
WNL and pain free throughoutLE strength
all WFL 5/5
4+/5 B hip ABD, extHip ROM:
WNL and pain free throughout
(-) hip special tests for intra/extrarticular involvementNeuro screen:
intact to light touch throughout LE
5/5 myotomes throughout
(-) neurodynamic tests(+) pulling sensation on L testicle with resisted adduction from max range abduction
(-) hip flexor length test
(-) L FABER
(-) resisted hip flexion
(-) resisted hip ADD in neutral
(-) L hip ABD PROM
(-) TLJ provocation testing
(-) rectus abdominis contraction against gravity/resistanceno palpable tenderness to adductor tendons, ERs, IRs, hip ext/abd/flex
Treatment:
STM: tacking and stretching adductor tendons
(no change following Tx)TE:
SL hip adduction
SL squat with functional reach/cone taps
Side plank w/ hip abd
prone plank hold
push up position bird dogs
(no change following TE)Any thoughts/experiences with this kind of presentation?
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Hey Nic Great case
I have had a few patients with athletic pubalgia. I had one here in fellowship that I wrote up.
Ended up treating with a pubic ramus AP mob and an SIJ manipulation which improved the pain. He was more irritable and had more provoking activities.i would def do PA assessment to fully clear lumbar and SIJ. Something that came up over and over in the literature on the topic
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Here is a good resource from Medbridge, I haven’t looked in depth for research regarding this condition. I would be curious as to an update with your patient as I have felt like the patients I have seen with similar symptoms were difficult to manage.
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This post got lost in limbo somehow, sorry for hijacking your post Kyle/Nic.
I have seen 2 patient’s with similar symptoms and demographics and one patient I am currently seeing that is an adolescent. None of these patients have been mildly irritable like your patient.
My thoughts on additional testing for this patient would be a gait/running analysis and tests of abdominal strength and endurance to see if these are contributing to diagnosis. It seems like this will be a tough patient to categorize due to his minimal irritability. I always have more difficulty with these patient’s due to the difficulty in reproducing their symptoms in clinic. Reassessing some of the LE and lumbar ROM with combined motions and axial load may add some value, but he seems like someone you may have to fatigue before his symptoms show up.
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Please review this article – posted Weekend 3 in the light of this patient case.
I love this article for the Clinical Reasoning/Exercise Prescription (library builder)
Post thoughts on the specific patient presentation from points in the article
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Cool Case. Any updates yet?
After reviewing the article and based on your patient’s lack of reproducing signs except for 1, I would love to see some femoral nerve testing or mobilization, and maybe get creative with different ways you could tension/glide the ilioinguinal/genitofemoral nerves, and see if that re-assessment sign improves.
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Nic,
One question I had was that you put that imaging was negative, and I was curious what sort of imaging that was and on what body region?Also just wanted to clarify, when you put all hip extra-articular testing negative, does that include femoral neck stress testing and patellar percussion for stress fracture?
Given the patients low irritability, and classification in the strength/stability group, I think I would want to see some objective testing of hop distances. I know you tested them for pain provocation, but if you are having a hard time finding adequate things to reassess and measure progress, a battery of single leg hop testing might be helpful.
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